Provider Demographics
NPI:1144325267
Name:BROWN COUNTY HEALTH CARE CENTER BAYVIEW DEVELPMENTAL CENTER
Entity type:Organization
Organization Name:BROWN COUNTY HEALTH CARE CENTER BAYVIEW DEVELPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INPATIENT SERVICES DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIVONKA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS, APNP, NHA
Authorized Official - Phone:920-391-4700
Mailing Address - Street 1:2900 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5859
Mailing Address - Country:US
Mailing Address - Phone:920-391-4700
Mailing Address - Fax:920-391-4870
Practice Address - Street 1:2900 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5859
Practice Address - Country:US
Practice Address - Phone:920-391-4700
Practice Address - Fax:920-391-4870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2986320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21050800Medicaid